Instant Access Insurance Verification

This form was created to help you verify your insurance benefits.

This form must be completed in its ENTIRETY prior to your prep appointment or we will not bill your insurance for the procedure and you will be expected to pay up front.

Our colorectal surgeons are preferred with Aetna, Blue Cross Blue Shield/Premera, Cigna, United Health Care, UMR, MODA, and EBMS.

We are not able to bill TriCare, VA, or Alaska Native Health Consortium.

TriCare for Life can be billed as a secondary only after Medicare has been billed.

Please have the following information available when calling your insurance company:

Insurance Company Name

Insurance Company Phone Number

Patient Name

Patient Date of Birth

Policy Holder Name

Policy Holder Date of Birth

ID Number (including prefix)

Name of representative you talked to

Date & Time

Our information you may need for the call:

Alaska Colorectal Surgery 2751 Debarr Road Suite 280 Anchorage, AK 99508

TAX ID: 920177040

June M. George, MD NPI: 1891735346 Kerrie R. Bossard, MD NPI: 1548267032

Daniel C. Rossi, DO NPI: 1568660835 Rebecca K. Rowen, MD NPI: 1427465392

You may be asked to provide procedure (CPT) codes, the following can be provided to determine if the codes are valid to be billed and if pre-certification is required:

45378 45380 45385

If diagnosis codes (ICD-10) codes are requested, provide any of the following that apply to you:

Z12.11 (screening colonoscopy) Z86.010 (personal history of colon polyps)

Z83.71 (family history of colon polyps) Z80.0 (family history of colon and/or rectal cancer)

1) Tell the representative that you are calling regarding physician service benefits for a screening colonoscopy.

Procedure code (CPT): 45378 Diagnosis code (ICD-10): Z12.11 Cost of procedure: $1885.00

Most insurance companies will cover a screening colonoscopy for age 45 and up, but some employer sponsored plans may opt to not cover screening colonoscopies until age 50 and up. Be sure to ask the representative if there are any age restrictions.

The CPT code and cost above is only an estimate for a screening/routine colonoscopy. If a polyp or another condition is found then your procedure and diagnosis codes will change and may result in your colonoscopy becoming diagnostic/medical.

Procedure code (CPT): 45380 Diagnosis code (ICD-10): D12.0-D12.9* Cost of procedure: $2300.00

Procedure code (CPT): 45385 Diagnosis code (ICD-10): D12.0-D12.9* Cost of procedure: $2671.00

*Specific code is dependent on location of neoplasm.

2) What is my yearly individual deductible?

How much has been met?

Co-pay only plan?

Yes No

What is the PROFESSIONAL co-pay?

What is my yearly family deductible?

How much has been met?

3) What is my yearly out-of-pocket maximum?

How much has been met?

Are the multiple tiers?

Yes No

What is the yearly family out-of-pocket max?

How much has been met?

Are the multiple tiers?

Yes No

Second tier individual out-of-pocket maximum?

How much has been met?

Second tier family out-of-pocket maximum?

How much has been met?

4) What is my co-insurance level?

Is there a second tier co-insurance level?

Yes No

What is the second tier co-insurance level?

5) Is pre-certification required for this procedure?

Yes No

Number to call for pre-certification:

7) If Alaska Colorectal Surgery is not a preferred provider with your insurance, please secure the amount your insurance company will pay. For some services insurance carriers will state they will pay 100% of usual and customary.

8) Ask for a call reference number once your call is completed:

I understand that the above are estimates only. I understand that I am financially responsible for any remaining balances after insurance pays, and that they must be paid within 10 days. Full payment will be required at the time of pre-op appointment if this form is not completed in its ENTIRETY.

Signature of Patient/Legal Guardian

Date

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